Breech Presentation

The fetus presents with the buttocks or feet, rather than the head, closest to the cervix.

Present in roughly 3 to 4% of pregnancies at term, though considerably more common earlier in pregnancy given that most fetuses spontaneously turn to cephalic presentation by around 36 weeks.

Classified as frank breech (hips flexed, knees extended, feet by the head, most common), complete breech (hips and knees both flexed), and footling breech (one or both feet presenting below the buttocks, carrying the highest cord prolapse risk).

External cephalic version (ECV) is offered from around 36 weeks in nulliparous women and 37 weeks in multiparous women, for persistent breech presentation without contraindication (major uterine anomaly, ruptured membranes, significant antepartum hemorrhage in the current pregnancy, multiple pregnancy other than after delivery of the first twin, or a fetal heart rate abnormality); success rate is roughly 40 to 60%, higher in multiparous women; a tocolytic (nifedipine or a beta-agonist such as terbutaline) may be used to relax the uterus and improve success
Anti-D prophylaxis for Rh negative women undergoing ECV given the risk of fetomaternal hemorrhage
If breech presentation persists, options are planned cesarean section or planned vaginal breech birth, following shared decision-making; planned cesarean is associated with a small reduction in short-term neonatal morbidity but does not clearly improve long-term outcomes, and vaginal breech birth remains a reasonable option in appropriately selected women (frank or complete breech, adequate pelvis, estimated fetal weight appropriate, no hyperextension of the fetal head) managed by an experienced practitioner
Vaginal breech birth requires continuous fetal monitoring, an experienced accoucheur, and immediate access to cesarean facilities, given the risks of cord prolapse (particularly footling breech), head entrapment, and birth trauma
Footling breech in labor, or breech presentation with a contraindication to vaginal birth, is delivered by cesarean

Referral: obstetric-led care; specialist counseling for ECV and mode of delivery decision-making.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Perineal Tears

Trauma to the perineum occurring during vaginal delivery, classified by degree: first degree (skin only), second degree (perineal muscle involved, not the anal sphincter, the most common significant tear), third degree (involving the anal sphincter complex, further subdivided 3a, less than 50% external anal sphincter thickness torn; 3b, more than 50% torn; 3c, internal anal sphincter also torn), and fourth degree (extending through the anal sphincter complex into the rectal mucosa).

Third and fourth degree tears are collectively termed obstetric anal sphincter injuries (OASIS).

Risk factors include nulliparity, instrumental delivery (particularly forceps), macrosomia, occipito-posterior position, prolonged second stage, and shoulder dystocia.

First and second degree tears: repaired under local anesthesia (or existing regional analgesia) using absorbable suture material, with a continuous, non-locked technique for the perineal skin generally associated with less short-term pain than interrupted sutures
Third and fourth degree tears (OASIS) require repair in theatre under regional or general anesthesia by an appropriately trained practitioner, given the technical demands of sphincter repair: the torn sphincter ends are identified and repaired (commonly using an end-to-end or overlap technique for the external anal sphincter), with the internal sphincter, if torn, repaired separately, and the rectal mucosa (fourth degree) closed first
Broad-spectrum prophylactic antibiotics are given at the time of OASIS repair (commonly a single dose or short course, e.g. IV co-amoxiclav or cefuroxime plus metronidazole), given evidence this reduces wound infection and breakdown risk
Laxatives (a stool softener such as lactulose, often combined with a bulking agent) are routinely prescribed after OASIS repair to reduce straining and protect the repair
Analgesia (regular paracetamol and NSAIDs, with opioids as needed), and physiotherapy input for pelvic floor exercises
Follow-up at 6 to 12 weeks in a dedicated perineal clinic after OASIS, assessing continence and wound healing, with endoanal ultrasound and anorectal manometry available where symptoms of incontinence or urgency persist
Counseling regarding mode of delivery in a subsequent pregnancy after OASIS is individualized, with the option of elective cesarean discussed, particularly if the woman remains symptomatic

Referral: appropriately trained obstetrician for repair of any third or fourth degree tear; dedicated perineal clinic follow-up after OASIS; colorectal surgery for persistent, significant incontinence despite conservative management.

Breech Presentation

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management